Accountants started with work sheets which are ruled ledger forms, to get a picture of the financial status of a company. With computerisation, the manual work sheet has evolved into the electronic spreadsheet, a powerful tool indispensable to the accounting profession. In an electronic spreadsheet, there is a huge grid of cells in which one can enter numbers or formulae that will perform calculations based on the values of other cells. Other than the occasional spreadsheets that allow text string entries and provide basic string manipulations for use as headers, the spreadsheet is essentially a number calculation device. The spreadsheet calculates the numbers and gives the accountants quick answers to "What if?" type queries. The results of this "What if?" analysis are placed in the spreadsheet cells, this sets up the conditions for the next round of calculations with no manual transcription. The accountant's electronic spreadsheet is prodigious for tasks that require repetitive work with a hand held calculator. Hitherto, there is no such equivalent spreadsheet in the medical or legal domains with the capability of, during a client encounter, i) data entry and recording ii) performing "what if" calculations pertaining to client diagnosis and management, with results placed in cells for the next round of evaluation and iii) a spreadsheet with features such as scrollable work sheets that can be saved.
The present invention relates to an approach which allows the traditional accountant spreadsheet to be adapted to other applications, eg for use in a real or simulated patient or client encounter environment or in the legal environment. Whilst the following description is with reference to the medical and legal fields, the invention is not so limited.
Traditionally the manual/electronic medical record keeping may be divided effectively in three modes: 1) fully manual, 2) manual cum electronic, and 3) filly electronic medical record system.
Current manual medical record systems are not properly designed from the information flow viewpoint. In particular, hitherto there is difficulty in presenting encounter data and global patient data using the same medical model. The end result is poorer patient care which can be attributed to medical information being hidden or lost in the jungle of data in a patient medical record regardless of its medium. While the best of the current crop of medical record systems as epitomised by the Problem Oriented Medical Record/Subjective Objective Assessment Plan model (POMR/SOAP) by Lawrence Weed (Medical Records, Medical Education and Patient Care. Cleveland: Case Reserve Press 1969.), attempts to structure medical record in a logical manner, it still does not lend itself to smooth information flow and effective computerisation as there is a schism in the day of consultation encounter data model and the patient global health status data model.
The present day medical record systems, regardless of whether they are manual or electronic, do not promote clear thinking in the mind of the clinician, pointedly there are no formal relationships among the various sections of the medical record. Present day record systems can be described as incongruous, non-optimised, and when computerised end up as a non-optimal systems also.
Current manual medical records are not designed for quick and accurate evaluation of patient clinical health status. Patient health data is often buried in clinical notes, important and exceptional patient data are often hidden from the health workers due to poor record design. This leads to medical accidents and potential litigation. There is potential to achieve better health outcomes and better quality patient care by not doubling on medical investigations, not missing tests that ought to be done, maximising available information and reducing litigation by overcoming current weaknesses in medical recording. Such weaknesses include the lack of a section for well defined diagnoses to precede treatment and sections reserved for evidence to support such clear diagnostic entities.
There also exists the promise of improved patient care by the computerisation of patient medical record. However this is tempered by the uncertainty over the veracity and legality of computerised medical records in medical litigation. This is one argument to keep some form of written notes. Keying in notes or dictating into a microphone by the clinician during the consultation process is acceptable only to a minority of doctors who are also technologically competent. The above would suggest that an ideal health record system for some doctors would comprise both manual and electronic elements.
Current medical record design is not conducive to rapid and effective evaluation of patient clinical status in its paper format. Any hope of leveraging the power of electronic computation into the medical record domain is predicated on a congruent patient health data model that is functional in both the manual and electronic medical record situations. Hitherto the paper medical record has been hard to computerise as there does not exist a congruous data model of the patient medical record that is effective for both the manual and the electronic medical record version. The Problem Oriented Medical Record of Weed is difficult to computerise as there is a separate data model for the encounter called SOAP and a global model of the patient called the problem list.
Another barrier to medical computerisation and mentioned above, and of a greater magnitude, is that pertaining to disruption of the doctor's work flow during the consultation. The traditional approach of pen and paper works well during a consultation as there is minimal disruption to the consultation process. During this process, the doctor has to concentrate on verbal and body language cues to achieve optimal communication with the patient; while at the same time, in a discrete manner makes notes and conducts an evaluation process in his or her professional mind.
To type in notes or to dictate into a voice recognition system during a consultation are strong disincentives for the majority of doctors to computerise their medical notes. Yet the computer is a powerful tool for making quick evaluation of patient status such as calculating, tracking the date of the last pap smear and recalling the patient. For instance in the tracking of pap smears the computer can easily work out to the nearest day since the last pap smear in a mere instant. The computer is also excellent in detecting drug interactions and disease-drug interactions. Hence, the quality of medical care can be promoted in a fully computerise medical record, as long as the medical data captured is structured in a way to be evaluated by the computer program. The scanning of word processed documents and medical images such as X-ray pictures to be placed into the patient electronic folder does not make use of the computer evaluation capacity at all and hence is a second rate implementation of the electronic medical record.
An inimical influence to the proper design of the manual medical record is the traditional teaching in medical schools to countless generations of medical students of the need to separate clinical symptoms and signs when approaching a patient clinical problem. In this paradigm, the consultation process begins with history taking (the collection of symptoms), this is followed by the physical examination of the patient (the collection of signs). Hence traditional medical notes will have two separate categories, one for symptoms and the other for signs. The traditional model of medical notes go like this: symptoms.fwdarw.physical examination/physical signs.fwdarw.assessment.fwdarw.treatment plan
This current art of the manual medical record system is described in the POMR/SOAP model by Dr L Weed (Medical Records, Medical Education and Patient Care. Cleveland: Case Reserve Press 1969.). POMR stands for Problem Oriented Medical Record while SOAP stands for Subjective Objective Assessment Plan.
This structured POMR/SOAP model is a vast improvement over other unstructured methods. Unstructured medical record keeping may lead to poor quality patient care and the propensity for medical negligence increases. Weed's ideas are implemented in the Royal Australian College of General Practitioners current paper medical record system and widely used in teaching hospitals in many countries.
In the problem oriented model, any unresolved or significant medical problem, be it a symptom, a sign, a diagnosis or an abnormal pathology result is collected into a numbered list. This problem list is placed on the first few pages of the patient record to jog the doctors mind as to the problems he or she has to grapple with. In the POMR/SOAP model, the ongoing case notes arising from consultation are encapsulated into the following categories referred to as SOAP: 1) Subjective--symptoms 2) Objective--physical examination/signs and objective test results 3) Assessment--doctor's opinion, but not necessarily a diagnosis 4) Plan--treatment, investigations.
However, the following are weaknesses of current medical record design, in particular POMR/SOAP.
1) The SOAP model is designed only for recording the encounter. The SOAP model cannot be used to represent patient global health status. For a comprehensive patient evaluation, we need in addition to clinical data collected for the encounter, at least the following information: current and past diagnoses, current medications, diagnostic imaging results, diagnostic non-imaging results. The POMR/SOAP model provides a problem list for the purpose of a comprehensive evaluation. An ideal health data model should be the same one used to represent encounter as the one used for global patient health status.
2) With the SOAP model, there is a self imposed chasm between symptoms and signs when recording. In reality, there is no clear logical demarcation between symptoms(subjective) and signs(objective) from an information science viewpoint. The patient can present to the doctor and clearly describe his i) lump ii) rash or iii) jaundice. These three entities are really physical examination signs or objective (in the SOAP terminology) findings. Often the patient volunteers the right diagnosis as well. Using these examples, all these data should strictly be recorded under as "symptoms" as they are information provided by the patient.
While the practice of eliciting symptoms and then proceeding to do a detailed physical examination cannot be faulted, there is no logical reason for the clinical recording to reflect actual clinical practice except for the purpose of training medical students.
3) With SOAP, abnormal test results are lumped in with signs. With the march of medical technology, the old paradigm is being left behind. Laboratory and radiology results play an overwhelming role in patient diagnosis, yet scores no space in the traditional paradigm or get lumped with clinical signs. A chest x-ray beats the most astute clinician with his stethoscope. From the information science viewpoint, the quality of a physical finding by examination is generally "less sure" compared to say a radiological finding or say an abnormal chemical pathology test. Abnormal laboratory and radiological test results are of a different predictive value and hence demands an almost exclusive category separate from clinical signs.
4) The assessment section of the traditional encounter model often holds the opinion of the clinician at the end of the consultation. It may be vague or non-diagnostic labels, such as "?appendicitis" "fever for investigation" "chronic abdomen pains". Often at the end of a patient encounter, a diagnosis is not even possible or at best only a provisional diagnosis made. From the information science viewpoint, the quality of the data placed in the Assessment section of SOAP notes are hard to evaluate in relationship to treatment.
5) There is a paradigm shift in the practice of medicine towards a heavy reliance on technology. Increasingly we see patients who are completely asymptomatic walk into a clinic and subject himself to screening tests for metabolic abnormalities, infectious disease or cancer. Not withstanding the fact that the art of eliciting clinical signs is important in medicine, it is clear that the results of a computerised axial tomography scan are of a different level of quality as compared to physical examination by palpation. Traditional clinical encounter recording has not integrated the modern practice of medicine with its current emphasis on technology.
6) The traditional medical record does not provide a tight framework for human/computer evaluation of the patient. For the purpose of machine evaluation one can refer to the computer chess paradigm. The evaluation of a chess position in a computer chess program may be used as the metaphor for the evaluation of a patient health status. In a chess position, the machine evaluates a position numerically based on a belief system comprising the following elements a) material advantage b) tempi-rapid development c) space advantage d) initiative--ability to launch threat e) attack on enemy pieces f) King safety g) piece activity, mobility and coordination h) pawn structure. With reference to each of these categories, the chess program ranks each candidate move with a numeric rating based on the strength of the resultant chess positions. A viable medical record data model is to be constructed like a belief system where the elements are linked in more formal relationships than we have seen in the current breed of medical records.
7) Overall, the existing encounter models lack precision in their theoretical foundation for the building of a manual/electronic medical record that provides a running score sheet of the patient health status from the encounter to the global level. POMR/SOAP is not facilitated for patient evaluation in the sense that the problem list structure is not closely relate to the SOAP encounter structure.
In summary, the traditional medical record model is not optimally designed from the information processing viewpoint. This poor manual record design means that they are not designed for easy computerisation.
Hence the problem is to come up with a) an appropriate evaluation model of the medical record that is effective and congruent for both the manual, hybrid manual/electronic, and fully electronic format of the medical record; b) a data model applicable for use in both the encounter and the global health data recording and evaluation; and c) overcome the man-machine interface problem (meaning no typing, no speaking into microphone when talking to patient) in computerisation of the medical record.
Turning now to the legal environment, during a meeting with his client, the lawyer needs to record the case details and constantly make evaluations of legal problems, resulting in dispensation of sound legal advice based on statute laws or precedents in common law cases. The traditional paradigm is based on textual narration of legal cases and key word search of electronic databases. Traditional legal practice has been quick to latch on to technology with computerised search engines and on-line databases.
The traditional legal model lacks the precision, required by computers, in its theoretical foundation for the building of an electronic legal spreadsheet. At issue is the creation of a legal belief system suitable for computerisation.